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World Nutrition Volume 5, Number 2, February 2014
World Nutrition
Volume 5, Number 2, February 2014 Journal of the World Public Health Nutrition Association Published monthly at www.wphna.org
The Food System: Ultra-processed products. 2014 Position paper
Product reformulation will not improve public health
Carlos Monteiro, Geoffrey Cannon Centre for Epidemiological Studies in Health and Nutrition School of Public Health, University of So Paulo, Brazil Emails: carlosam@usp.br; wn.theeditor@gmail.com
Manufacturers want to evade regulations and to increase profits by making and selling reformulated added value ultra-processed products with low sugar, low fat, low salt and other health claims
Monteiro CA, Cannon G. The Food System. Product reformulation will not improve public health. [Commentary] World Nutrition February 2014, 5, 2, 140-168 140
Summary
Reformulation to reduce fat or salt or sugar or to add various bioactive compounds enables manufacturers to imply or claim that ultra-processed products are healthy. They are not This 2014 position paper revises and updates the previous paper, published in WN in 2012. It is written from a global point of view. The points we make have special force in middleand low-income countries, and for impoverished populations in all countries. They also apply to high-income countries and settings, especially where dietary patterns are still food-based. Reformulation of processed food and drink products is a prime nutrition policy priority. It justifies public-private partnerships at which agreements concerning product formulation are made. Reformulation that reduces the amount of fat or sugar or salt, or that increases the amount of dietary fibre or vitamins or minerals or other bioactive compounds, will improve the nutrient profile of processed products. So it will result in healthier food supplies and dietary patterns, and help to control and prevent obesity and chronic noncommunicable diseases, as specified at the General Assembly of the United Nations. The paragraph above summarises the consistently stated view of government legislators, UN and other international agency officials, and leaders of influential organisations working in the public interest. It is also the stated view of the leading corporations that manufacture such products, and their representative, associated and supportive organisations. These continue to initiate, fund, resource, and set agenda for public-private partnerships designed to shape international food and nutrition policies. It seems that practically all stakeholders agree that product reformulation will improve public health. Our position, recently summarised in a Lancet commentary of which one of us is a coauthor, is that this view is wrong. Product reformulation has two main functions. One is as a type of new product development with the bonus of being able to make health claims and sometimes charge premium prices. Two is as a damage limitation exercise, a distraction from essential statutory measures that will effectively improve industrialised food supplies, protect traditional food systems, and create a fair market for the food industry as a whole, including family and independent farmers, retailers and caterers, as well as manufacturers. The net eventual effect of product reformulation, when this enables manufacturers to imply or claim health benefits, will most of all in the global South lead to deeper penetration and greater consumption of intrinsically unhealthy ready-to-consume ultra-processed products, Heavily promoted, these displace freshly prepared dishes and meals and eventually destroying food systems and cultures based on freshly prepared meals. Product reformulation is not part of the public health solution. It already is part of the problem.
Monteiro CA, Cannon G. The Food System. Product reformulation will not improve public health. [Commentary] World Nutrition February 2014, 5, 2, 140-168
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The case for and against
Plenty of fatty or sugary products are already reformulated to contain less or even no fat or sugar (above) and imply or make health claims. One question is, what are the replacement ingredients? Reformulation of food products is a topic that needs to be addressed regularly. This 2014 position paper revises and updates the previous paper, published in WN in 2012. Since then the issue of food product reformulation has become more urgent and important. More and more public bodies, including UN agencies and national governments, see reformulation as a powerful way to improve dietary patterns and protect against obesity and related diseases. Consortia of nutritionists are devising systems of nutrient profiling designed to promote reformulation. Action on Sugar, launched in the UK in January this year, has as the first and foremost goal, reformulation to reduce sugar in ultra-processed products. Also, and significant, manufacturers evidently welcome reformulation, especially when this is according to their own rules and when the reformulated products are labelled with implied or explicit health claims and endorsements from apparently independent sources, which add commercial value. This new 2014 position paper takes these and other developments into account.
The case for

There is a case for reformulation. When food products are reformulated with prevention and control of chronic non-communicable diseases in mind, their nutrient profiles of course tend to improve. If many customers buy reformulated products in place of standard or classic un-reformulated products, and if this switch is substantial, and if harmful ingredients are not replaced by other harmful ingredients, and if they make no other change in their diets (note the ifs), this may be of some benefit at personal and eventually even population level. Advocates of reformulation have published impressive estimates of reductions in morbidity and mortality from various diseases that could result from reductions in trans fats, saturated fats, sugar or salt, in processed products and thus in food supplies (1, 2). There is however no direct evidence that product reformulation alone is effectively reducing the prevalence of any disease. Indirect evidence is used instead. An example is the reduction of the volume of salt in the UK food supply that has taken place in recent years, as a result of a concerted campaign backed by the
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previous UK government in which reformulation has been one component (3-5). We think that the inference of benefit here for cardiovascular disease, but not for obesity, is reasonable. But whether really substantial changes in product composition or in public health are actually happening, and whether there is any increase in consumption of healthy unprocessed and minimally processed foods, which do not need reformulation, are other matters.
The case against

The case against product reformulation, particularly when used as a main strategy, has recently been summarised in The Lancet (6). The case against is more convincing. Reformulation is not of healthy foods. It is of inherently unhealthy products. These are usually identified in dietary guidelines as products to be consumed only occasionally. They are made merely somewhat less unhealthy by manipulation of their ingredients. Reformulation of the type volunteered by manufacturers or suggested by government officials, usually results in relatively small and sometimes even trivial adjustments in nutrient profiles of products that remain unhealthy (7,8). Voluntary product reformulation is a distraction from public health actions that will certainly have much more significant benefits. As with tobacco and alcohol products, such actions include statutory regulations. These need to include pricing and other statutory measures designed to promote healthy food, such as those that remove price support for unhealthy commodities, tax unhealthy products and restrict their advertising and availability especially to children, and thus protect the public interest and promote well-being. Such policies, analogous with those that control the use of toys, cars, guns and drugs and use of tobacco and alcohol are now being considered by a number of governments and have been enacted by others (9-11). As things are now, voluntary guidelines on reformulation of inherently unhealthy ultra-processed food products are agreed or confirmed by public-private partnerships. In these, the public partners include officials from UN and other international organisations, and politicians and officials from national governments, with a notional presence of public interest organisations. Journalists are usually not let into the process. The private partners are predominately marketing and publicity executives of transnational corporations whose sales and profits derive mainly from unhealthy products, together with their hired, representative, associated, and supportive organisations, with practically no representation from any other industries. Use of the term partnerships implies that the corporations are sharing in responsibility for the public interest, notwithstanding their duty to maximise their bottom lines, share price, sales volume, and market presence (12). Above all, the case against reformulation is that it is part of a deal, as a result of which regulatory authorities sanction or tolerate explicit or implied health claims of the types shown in the pictures that introduce this commentary. These enable
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reformulated products to be advertised as positively healthy foods, and thus yet more attractive than whole or minimally processed foods, and often sold at increased premium prices. Within the global North, especially in regions like Southern Europe and the Middle East whose food supplies are not yet saturated with ultra-processed products, common sense suggests that the net effect will be overall increased purchase and consumption of these products, most with implicit or explicit health claims. In the global South, the prospect is disastrous. The penetration of ultra-processed products into countries in Asia, Latin America, Africa and other countries of the global South whose dietary patterns are food based, already at the rate of doubledigit (10 per cent or more) annual growth (13,14). Reformulated with health claims this penetration will become deeper. Up to the second half of the last century few adults consumed snacks. Now, in countries such as the US, Canada, Mexico, Brazil and China, products in snack form amount to up to a quarter of all calories consumed. In China, since 2000 snacking has tripled every two years (15). The results are bound to include acceleration of the displacement of traditional and well-established food systems which, when they generate adequate and varied supplies of fresh and minimally processed foods, are the basis of economical, rational, appropriate, and healthy dietary patterns. (See Box 1).
Box 1 The duty of governments

We are not critical of the food industry as a whole. Any such position would be absurd. Industry always has been and should be a driving force of society and civilisation, and a source of security and well-being. Properly defined, the food industry includes hundreds of millions of farmers, traders and makers throughout the world who generate healthy and delicious food. It also includes producers and manufacturers of fresh and minimally processed food. Our concern is with the damage done as a result of the unbridled commercial freedoms that since the 1980s, have been recklessly ceded by elected governments to transnational industries of all types, whose activities are contributing to the fuel, finance and food crises that now beset us, and are undermining and displacing healthy food systems. The obesity pandemic, a crisis in itself, is also a sign of systemic failure, of world disorder. It is the nature of commercial enterprises always to push for profits. The original fault here lies with legislators who have abandoned their duty to regulate industry in the public interest. Professional, health, and other civil society leaders, who have combined and pressed for rational and healthy policies and actions concerning tobacco, have not yet done so in the case of ultra-processed food products. We believe this time must and will come.
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Reformulated products are unhealthy
Centre aisles in supermarkets. Reformulated products remain ultra-processed. Fatty salty snacks like chips (crisps) and sugared soft drinks may be reformulated and marketed as if they are healthy Much discussion about reformulation seems to assume or imply that manipulation of the ingredients of food products will make them healthy. This is not so. It is ultraprocessed products, which are principally formulations of industrial ingredients, that are reformulated (15,16). Reformulated products still contain little if any whole food. However modified or recombined, they are still almost all processed fats or oils, and/or sugars or syrups, and/or starch or starchy material, with other processed ingredients, salt, preservatives, and other including cosmetic additives. (See Box 2).
Box 2 Ultra-processed products

Ultra-processed products are made from processed substances extracted or refined from whole foods, such as oils, hydrogenated oils and fats, flours and starches, sugars and syrups, and cheap parts or remnants of animal foods, with little or no whole foods. Examples include carbonated and other sugary or syrupy drinks; breakfast cereals, chips (crisps), cookies (biscuits), confectionery, and other fatty, sugary or salty snack products anmd instant noodles; burgers and other meat products, frozen pizza and pasta dishes, chicken and fish nuggets and sticks. Most are made, advertised, and sold by transnational and other very large corporations, are very durable and palatable, and are ready to consume, which is an enormous commercial advantage over fresh and perishable whole or minimally processed foods Ultra-processed products are typically energy dense; have a high glycaemic load; are low in dietary fibre, micronutrients, and phytochemicals; and are high in unhealthy types of dietary fat, free sugars, and sodium. When consumed in small amounts and with other healthy sources of calories, ultra-processed products are harmless. But intense palatability, achieved by their high content of fat, sugar, salt, and cosmetic and other additives, omnipresence, and sophisticated and aggressive marketing strategies such as reduced price for super-size servings, all make modest consumption of ultra-processed products unlikely and displacement of fresh or minimally processed foods very likely. Reformulation does not and cannot change their basic nature. Adapted from (6). See also (15-19).
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Oreos are the biggest selling cookie in the USA. They come in many varieties. Classics include the Double Stuf (left). Healthy tastes are accommodates by reformulated lower fat or sugar free versions When some reduction in the amounts of fats, saturated fats, sugars or salt is made, the products still contain little if any whole food. They remain energy-dense. They remain fatty, sugary or salty, are still formulated from cheap ingredients, and remain ultra-processed. The same is true when synthetic or other micronutrients or bioactive compounds are added. Ultra-processed products are not simply another type of processed food product. Processed products like tinned fish or fruit, say, or ham or smoked fish, are recognisable as foods modified by processing. Ultra-processed products may have some food in them but are formulations of industrial ingredients. This means that they can be, and are, formulated in all sorts of ways. Take the Oreo cookie (above). Invented a century ago, over 50 billion Oreos have been eaten, and it is now a $1 billion a year seller for Mondelz (formerly Kraft) the third biggest transnational food product manufacturer. Once upon a time there was the classic Oreo. Varieties now include the Strawberry Milkshake, the Blueberry Ice Cream, the Banana Split, the Double Delight, the Birthday Cake, and maybe up to 50 others, including the Oreo equivalent of the Big Woppa, the Double Stuf (above left). Usually Oreos are about 75 per cent fat and sugar. But they can be readily reformulated to be reduced fat (above, middle), and also sugar free (above middle). Their formulation and ratios of fat and sugar is infinitely manipulable, as are the formulations of countless other ultra-processed products. So if sugar (in the form of sucrose) comes out of the sugar-free Oreo, what goes into it instead? Its ingredients in order of amount, are maltitol (a polyol of sugar alcohol made by hydrogenation of maltose), unbleached enriched flour (wheat flour, niacin, reduced iron, thiamine mononitrate, riboflavin, folic acid), canola oil and/or palm oil, polydextrose, cocoa (processed with alkali), cornstarch, glycerin, inulin, emulsifiers (vegetable mono-and diglycerides, soy lecithin), baking soda and-or sodium acid pyrophosphate and-or calcium phosphate), salt, dextrose, natural and artificial flavour, cellulose gum and gel, chocolate, heavy cream, acesulfame potassium and sucralose (sweeteners). In other words, the sugar (sucrose) is replaced with a non-sucrose type of sugar, extra flour, starch, bulkers and gums, and chemical sweeteners. The sugar-free Oreo is roughly as energy-dense as the classic cookie and sells for twice the usual price.
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Not a lot changes

Discussion also often seems to assume that reformulations of the types now offered by manufacturers and endorsed by government officials and regulatory agencies, will make some sort of big difference and result in food supplies dominated by products that are very different from previous versions. This is also not so. In a trade journal, Joost Blankestijn explains why (21). He is business development manager of food innovations for the Dutch company TNO (Organisation for Applied Science). Its mission is to convert research findings into profitable business. With 5,000 employees, it is the largest enterprise of its type in Europe. He says: Reformulating products is a key trend in the food industry. Manufacturers try to reduce the content of unhealthy ingredients like fat, sugar and salt. Omitting an ingredient is easier said than done. Lowering the salt content may diminish the taste, texture and shelf life. Less trans fatty acid in food often increases the content of the almost as unhealthy saturated fat in order to retain the products properties. Moreover, reformulation generates higher costs for raw materials and processing, costs that manufacturers are trying to keep as low as possible. Many products, including lead lines, can be and already have been reformulated. But their basic nature does not change. Voluntary reformulation strategy is also affected by the determination of manufacturers to preserve the ultra-palatability and habitforming qualities (22,23) provided by sophisticated combinations of additives, fats, sugars, and salt. Usually the changes made when products are reformulated are small or even trivial, apart from sharp reduction or elimination of trans-fats. (See Box 3).
Box 3 Removal of trans-fatty acids

Trans-fatty acids, also known as trans-fats, are generated by the partial hydrogenation process. This has been used for 100 years by manufacturers and their suppliers to convert liquid oils into solid fats, so as to create stable fatty products with long shelf-lives. Any product that contains partially hydrogenated oils or fats, therefore contains trans-fats. These chemically created artificial substances are known to be intensely damaging to the cardiovascular system (25,26). Regulatory authorities and industry have agreed to reduce industrially-generated trans-fats in ultra-processed products, and this measure is increasingly in force now. This has no place in any reformulation policy. It is not reformulation. It is removal of a toxic substance. It should not be a voluntary arrangement, but the result of a worldwide statutory measure not requiring any partnership involving negotiation with manufacturers except on practical matters like timing. The most rational and effective action will be prohibition of the hydrogenation process in the manufacture of food and feed products (27,28).
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What private sector means

We now turn to discussion of the industries whose products may be reformulated. We have no specific criticism of any corporation or product. Our points are general. What we say of any corporation or product can be taken to apply to all. From the nutrition and health point of view, and indeed socially, economically and environmentally, any fatty salty packaged snack, any sugared breakfast cereal, and any sugary or syrupy soft drink, is much the same as any other. We are not critical of industry as a whole and we are not implying that manufacturers want their products to be unhealthy. Of course they do not. The fact is though, that it is the ready-to-consume energy-dense fatty, sugary or salty ultra-processed products with long shelf-lives, made mostly from very cheap ingredients and formulated to be intensely palatable, that are the most profitable. In order to stay in business and to thrive, corporations are bound to protect these products.
Private sector means the transnationals

Discussion of food product modification is in (at least) one respect, very odd. In the context of public-private partnerships, and the overall context of prevention and control of chronic non-communicable diseases, constant reference is made to the private sector. Out of context the term could be inclusive of the travel industry, say, or the banking, electronics, travel or furniture industry. It isnt, of course. In context, common sense would suggest that it includes all sectors of for-profit enterprises engaged in some aspects of food systems. But it doesnt. Maybe in theory it does, but in practice producers, distributors, and retailers are excluded, as are caterers (unless corporations like McDonalds and Yum! Brands count as caterers). So are representatives of farmers co-operatives. Why? The UN Food and Agriculture Organization states: It is estimated that one billion individuals are members of cooperatives, generating more than 100 million jobs around the world. In agriculture, forestry, fishing and livestock, members participate in production, profit-sharing, cost-saving, risk-sharing and income-generating activities (28). These billion people who produce food are evidently not counted as part of the private sector or part of the public sector either. They apparently dont count, period.
Or to be more precise, Big Snack

In practice, the private sector engaged with the UN and its agencies, national governments, and selected science and policy experts, to shape world policy on the prevention and control of chronic non-communicable diseases, is just one sector of the food and drink industries. Often termed Big Food, this sector is more precisely termed Big Snack (17,29). These are the colossal transnational purveyors of energyMonteiro CA, Cannon G. The Food System. Product reformulation will not improve public health. [Commentary] World Nutrition February 2014, 5, 2, 140-168
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dense fatty sugary or salty ultra-processed products and sugared or sweetened drinks. Each of them makes several or many $US billions a year profit from the manufacture and sale of their branded ultra-processed products. (See Box 4). Leading Big Snack corporations have pooled their common interests into the Intemational Food and Beverage Alliance, with offices perhaps unsurprisingly in Washington DC. In its March 2011 Five Commitments to Action (30), as updated on its website by August 2012, the first commitment of the IFBA is to reformulate products and develop new products that support the goals of improving diets and the fifth is to actively support public-private partnerships that support the WHOs Global Strategy. IFBA members include Coca-Cola, Pepsi-Co, Kraft, Kelloggs, General Mills, Mars, Nestle and Unilever. Why is Big Snack accepted as the principal private partner in policy-making at the highest level, designed to prevent obesity and related chronic diseases of which their products are a leading cause? In common with other colleagues, we have been asking representatives of the public sector this question in print, meetings and conferences, since the beginning of this century. We are still waiting for an answer.
Box 4 Transnational corporations

Transnational means reaching beyond or transcending national boundaries. Thus, transnational corporations, while usually headquartered in one country, have no special loyalty to any country or to anything else other than their own policies and ambitions. Their senior executives typically originate from various countries. They are different in nature from international or multinational corporations, which at least traditionally retain special commitments to their country of origin. The transnational way of doing business is an aspect of economic globalisation and a result of deregulation (31,32). Transnationals are more powerful than corporations that remain committed to a country of origin. The annual sales of the biggest transnational food and drink corporations are equivalent to the annual gross national product of middle-size countries (17,18). They go where the greatest commercial action is, and prefer countries whose governments offer them the most incentives. National governments are aware that transnationals will make investments and offer employment in those countries that give them most freedom and scope to do their business, including the country in which they happen to be headquartered. The countries in which transnationals are most powerful, include those in which regulation is least effective and whose governments are impoverished or heavily indebted, and thus in special need of foreign investment even when this involves selling off public goods such as land, electricity and water. Transnational business includes predatory competition with and takeovers of smaller national companies. This in part explains the tendency for transnationals to become oligopolies and even monopolistic, and thus not genuinely competitive. The front and trade associations and alliances formed by food manufacturing transnationals to protect their interests by for example resisting statutory regulation (30) show that they run as a pack. Developed from (6)
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What partnership means

Food and drink product reformulation is one rationale for public-private partnerships. Much of the initiative and material support for these partnerships has come from the transnationals, who seek to set agenda and establish priorities for policy discussions convened by UN agencies and national governments. The effect has been to give the chief executives of transnational food and drink corporations a status on a level with that of the leaders of national governments and United Nations agencies. This can be seen as part of a general global process whereby the responsibility of elected governments to protect public health and public goods, is being ceded to executives of corporations whose responsibility is to their shareholders and to the money markets. The commercial interests of the transnationals are powerfully served in meetings convened or organised by the World Economic Forum, and in policy initiatives involving the World Bank or the World Trade Organization. The transnational food and drink industries and their representative, associated and supportive organisations (33-35), are efficient and effective, and by definition operate globally. They hire the most imaginative and best resourced public relations agencies with a global reach. They have vast amounts of disposable cash to spend. They have plausibly asserted that their commercial interests need not conflict with those of public health. Consequently they are seen by the United Nations and its relevant agencies, and by the most powerful national governments, not as part of the public health problem, but as an indispensible part of its solution (36). Their own power and wealth, most of all at a time when the UN and its agencies, and national governments, are stuck in financial crisis, makes them leading partners in public-private partnerships. Very remarkably, Big Drink, the transnational alcohol industry and its representative organisations, is now also identified as a private partner in high-level UN and national government discussions designed to improve public health and to control consumption, despite alcohol certainly being carcinogenic and addictive (37,38).
Reformulation is where the action is

The transnational food and drink corporations have in effect done a deal in partnership with national governments and their regulatory agencies. This is that in return for voluntary reformulation of their products to their own specification, they may promote them with explicit or implicit health claims. This they may do even to the extent of using quasi-medical claims sanctioned or tolerated by government agencies even in well-regulated countries, which are sometimes supported by on-pack endorsements from medical and health organisations.
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Product reformulation is a type of new product development, with sanction to make health or medical claims, as with anti-cholesterol breakfast cereals and margarines. Sometimes these may go too far In part this is a damage limitation exercise designed to neutralise health professional, civil society and other public interest organisations, and to circumvent the duty of governments to regulate harmful commodities. But there is a context. Food manufacturers have been reformulating their products for decades, so as to be able to imply or make health or medical claims. Reformulation is simply one type of new product development, without the risk and expense of launching a new brand. Retooling existing brands as health foods, or even as functional foods that will protect against, prevent and even treat disease, is a bonanza. Breakfast cereals and margarine (above, left and right) are examples. Sometimes, as with the yoghurt above claimed to boost immunity, these go too far and are prohibited by regulators. Manufacturers love product reformulation. It is a giant leap forward in new product development. We are going through a revolution in food says Thomas Pirko of Bevmark Consulting, the Californian company which advises governments, the chief executive officers and chief financial officers of the worlds top food and beverage companies, including Coca-Cola and Kraft. It's a whole new consciousness every product has to be adding to your health or preventing you from getting sick (39). One example is the US-based General Mills (GM), very big in ready-to-consume breakfast cereals (40-42). Two-thirds of its products by sales have been reformulated since 2005. These include its Big G breakfast cereal range, Honey Nut Cheerios (see above, left), Lucky Charms, Cinnamon Toast Crunch, and Cheerios. Mark Belton, GM executive in charge of global strategy, growth and marketing innovation, says: Health improvements have increasingly become a primary driver of our innovation, so we are careful to balance strong health benefits and health improvements with great taste (43). Like other breakfast cereals, the GM range is fortified with a lot of added minerals and synthetic vitamins. Children and their parents are also taken into account. In 2009 GM agreed to reformulate cereals promoted to children under 12, so as to contain single-digit grams of sugar per serving. This policy is also much the same as that of other corporations in the business of manufacturing breakfast cereals. Accordingly in 2012, Cinnamon Toast Crunch, Cookie Crisp and Cookie Crisp Sprinkles were reformulated to contain not 10 but 9 grams per serving. At either level roughly one-third of the weight of the products is added sugar.
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Case study 1 Reduced sugar Froot Loops
Many parents share concerns of health professionals on the amount of sugar in breakfast cereals formulated for children. Here, Zac Hemmerling shows the trouble with Froot Loops Froot Loops were formulated by Kelloggs in 1963. They feature Toucan Sam and are aimed at children. They are one of the 10 blockbuster top sellers, most aimed at children. The loops, made from extruded flour and sugar plus the ingredients below, come in red, yellow, orange, green, purple, blue, pink and gold colours and in banana, blueberry, lemon, marshmallow, orange and strawberry flavours (these vary in different countries). The colours and flavours are all artificial. About 40 per cent of the weight of the standard product is sugar. One ingredients list of a variety promoted as being a good source of dietary fibre (as above) is of 30 items plus unspecified flavours: Whole grain corn flour, sugar, wheat flour, oat flour, oat fibre, soluble corn fibre, salt (listed as sodium chloride), partially hydrogenated vegetable oil (so the product contains trans fats, although the nutrition label lists 0 trans fats), coconut oil, soybean oil, cottonseed oil, vitamin C, nicotinamide, F&DC red 40 (a chemical colour), lemon, cherry, raspberry, natural blueberry flavour (the word flavour applies to all names of fruits), lime, natural flavours, F&DC blue 2, turmeric. F&DC yellow 6, zinc oxide, annatto, vitamin B6, vitamin B1, vitamin A, butylated hydoxytoluene (giving the product a shelf-life of a year), folic acid, vitamin D. The total global breakfast cereals market is currently turning over $US 30 billion a year. Average profit to the manufacturer of breakfast cereals is about 40-50 per cent, not far off the profitability of pharmaceuticals. In the US sales of Froot Loops for the year mid 20122013 were $US 176,349,800. At an average price of around $US 4.50 a standard package of around 350 grams, that makes something like 40 million boxes each containing 12 30 gram servings, which makes 480 million servings a year in the US one and a half servings for everybody in the US. Given that of each 100 grams of cereal, 40 grams is sugar, a reduction of 30 per cent would amount to an overall reduction in the US of around 4,000 million grams or 4,000 tonnes a year. Just from one brand of cereal in one country. Big numbers. At a wild guess, if Froot Loops represents 5 per cent of the sugary breakfast cereal market and if the US currently represents say 20 per cent of the global market, factored up this would amount to a reduction of around a 400,000 tonnes a year, or something like 0.25 per cent of the total annual world sugar production of around 160 million tonnes. Very big numbers. Advocates of products reformulated so as to contain less sugar may not always be aware of the consequences. Froot Loops are the case study here because they do have a reduced sugar variety, and to contents of the product, and the consequences, are known .
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For over ten years Froot Loops have been marketed in reduced sugar (left) or one-third less sugar (centre, right) versions. So have other sugary breakfast cereals aimed at children Since 2003 Froot Loops, like other intensely sugared breakfast cereals, have a variety formulated to contain less sugar, as shown above (left). A one third less sugar version is also in the centre of the supermarket aisle (right). The reduced sugar versions of Froot Loops add refined starchy carbohydrates, so the product contains the same amount of calories. Some manufacturers add chemical sweeteners and charge more. The version above makes a series of implied health claims. The banners say Excellent source of vitamin C, Multi-grain, 11 vitamins and minerals (which are synthetic), Natural fruit flavours (meaning artificial but nature-identical), and No artificial sweeteners. As explained on the Kelloggs website: Sugar in cereals including kids cereals contribute less than 5 percent of daily sugar intake. Yet it adds taste, texture and enjoyment to cereal, while encouraging the consumption of fiber, vitamins and minerals (45). The reduced sugar varieties were analysed and no benefit was identified. You're supposed to think it's healthy," said Marion Nestle, nutrition professor at New York University. "This is about marketing. It is about nothing else. It is not about kids' health." (46) The benefit is to the manufacturers. In their first year on the market, sales of reduced sugar sugary breakfast cereals increased by 50 per cent, obviously because parents thought they are healthy, which they are not. Worse, because of the bran and synthetic vitamins and minerals in them, the nutrient profile of Froot Loops qualified for a US Smart Choices seal of approval, (see below), devised with industry by a consortium of nutrition professors and the American Society of Nutrition, but later withdrawn after a storm of protest and ridicule (47). Worse yet, if products like this that imply or state health claims, are marketed aggressively in the global South, they will rapidly displace traditional healthy breakfast dishes.
In the US, Froot Loops were given a industry-funded quasi-official Smart Choices seal of approval, because their nutrient profile ticks the boxes This tick was later withdrawn
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The global North
In the US, products invented or reformulated to contain no sugar are power brands. These include designer waters like zero Vitaminwater (left) worldwide and zero cola here in Japan (right) Almost all interest in processed product reformulation comes from the global North. Here, the North is taken to mean the high-income mature market economies of North America, Europe and some other countries, and the South is taken to mean the middle- and low-income emerging market economies of Asia, Africa, Latin America and some other regions and countries. This is a rough classification: some regions in the North still retain traditional food systems. But almost all analysis of the significance of product reformulation is of its impact on the health of fully industrialised populations in the global North. Any such analysis assumes that what goes for the North applies globally and therefore also to the South. It does not. The circumstances of most countries in the North are very different from those of most regions and countries in the South. High-income countries generally became economically developed a long time ago. Two examples are the US and the UK. As a result of industrialisation, urbanisation, and the displacement of indigenous and rural populations, previously long-established and traditional food systems and culinary and dietary traditions have been pushed into niches or even practically vanished, to be evoked nostalgically at Thanksgiving, Christmas, and other feast-times. Consequently, for generations now, a high proportion of the food purchased and consumed by most people has been in the form of products that are ready-toconsume. Preliminary research of food consumption trends indicates that the food supplies of mature market economies such as those of the US, Canada and the UK may now be saturated with these ultra-processed products, with little scope for further increase, at a consistent average national level of over 60 per cent of total energy (48,49). In such countries obesity was already identified as a public health problem by the 1970s, and rates have accelerated since the 1980s. In the US, population prevalence of obesity is around one-third, and of overweight and obesity combined is about two-thirds (50). In the UK and Canada, prevalence of obesity is close to one-quarter of the population, and of overweight and obesity combined, just over three-fifths (51,52).
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Saturated markets in the North

In countries with a fully industrialised food system and very high rates of obesity, the public health case for the reformulation of food products is apparently strongest. When markets for ultra-processed products are saturated, such that populations are literally filled up with them, consumers may tend to prefer new products positioned as healthy, instead of the standard products. If they can afford such products even when these are more expensive, and if they do not overall increase their consumption of energy-dense fatty, sugary or salty ultra-processed products, then product reformulation, and also new healthy products, should have some benefits, for those people who are able to make such choices, and actually do so. This may now be a trend in the US, where sales of sugared soft drinks have gone flat, and sales of alternatives including designer water are increasing (53-55). The change became evident about seven years ago. Coca-Cola chief executive officer Muhtar Kent said in 2007: When we walk around the US market, it's like we've lost the drive to create impulse, and we want to bring that back. He added In Latin America, Europe, Asia, North Africa, it says everywhere Ice cold Coke served here. Not in the US (56). In other words, there is not much fizz left in countries like the US or the UK. But there still is some scope for growth. More sales and profits can come from literal expansion of waistlines, or predatory competition and takeovers, or purchase and exploitation of public goods such as water supplies or products formulated or reformulated so as to enable health claims, bigger sales, and higher prices.
In the North, distraction

Thus in mature market economies like the US and UK, where most of the dietary energy in the food supply comes from calorie-dense ultra-processed products, and where most people are overweight and obese and also have disposable incomes, product reformulation may have some health benefits. But given health claims some of which suggest quasi-medicinal benefits, common sense suggests that the net result, even in countries whose food supplies are practically saturated, is likely to be an even greater consumption of ultra-processed products, some positioned as enjoyable and even glamorous, others as healthy or even as vital protection against disease, and many with premium prices, which increase inequity. Coca-Cola is a strong supporter of public-private partnerships, and of reformulation and new product development. On obesity Muhtar Kent says: This is an important complicated societal issue, that we all have to work together to provide a solution. That's why we are working with government, business and civil society to have active lifestyle programs in every country we operate by 2015 (57).
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The global South
Ultra-processed products have deeply penetrated Asia, Africa and Latin America. Here are a floating supermarket from Nestl in Amazonia (left) and a Pepsi shop hoarding in India (right) We now turn to the global South. Here is what WHO director-general Margaret Chan has said: Today, many of the threats to health that contribute to noncommunicable diseases come from corporations that are big, rich and powerful, driven by commercial interests, and far less friendly to health. Here is a question I would like to ask the food and beverage industries. Does it really serve your interests to produce, market, globally distribute, and aggressively advertise, especially to children, products that damage the health of your customers? Does this make sense in any mission statement with a social purpose? (58).
Box 5 Regulation in the public interest

Wise laws protect the public interest. The use of roads is usually tightly regulated. Traffic signals, vehicle and cycle lanes, road signs, speed limits, driving tests, penalties for reckless or drunk driving, requirement for seatbelts, subsidies for lead-free petrol, have been welcomed by the public and accepted, often after resistance, by industry. They reduce injury and death of drivers, cyclists and pedestrians, and increase the pleasures and freedoms of travel. They have encouraged industry to be innovative and ingenious and to make safe cars. All social and economic activity needs rules and regulations. Sport would be chaotic without rules, or with rules that were ignored. But transnational food and drink product corporations have largely evaded regulation. This is probably because their rise coincided as from the 1980s with governments in the US, the UK and then elsewhere, whose leaders were ideologues committed to avoidance or abandonment of regulation of industry. In practice much regulation in place before that time has remained in force. But as from the 1980s industry has been enabled to become transnational at phenomenal speed, by being given almost complete commercial freedoms. The theory was that the race should always be to the strong, and all would gain as a result. As we know now, this theory is mistaken. After the 19th century it became well understood that careful regulation discourages ruthless business, and enables enterprise whose effects are more socially responsible. This is a lesson that needs to be learned for the 21st century.
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Booming business in the South

As with the European colonial powers in the 19th century, now that the South is opened up all the transnationals are determined to get a share of the action. They are bound to do so. Any corporations slow to enter emerging market economies would be taken over by energetic competitors. This is the nature of the business economy. For transnational corporations, the global South is where the action is (53). In June 2012 Coca-Cola announced that it was investing $US 4 billion in China, and accelerating its investment in India to $US 5 billion by 2020 (60). Coke has invested heavily in fast-growing emerging markets such as China and Brazil with $15 billion brands that include Sprite, Minute Maid, Powerade and its namesake cola (61). In the three years between 2008 and 2011, Coca-Cola profits doubled, from $US 5.8 billion to $US 11.8 billion. Currently sales are rising by an annual 2 per cent in the US, 9 per cent in China, and 20 per cent in India (57, 60) In March 2012 Muhtar Kent opened the biggest bottling plant in China, occupying 170,000 square metres (42 acres), with a capacity for 5 billion servings a year. China is a vast growth market for Coca-Cola he said: As we work to double the size of our global business in this decade, China will play a critical role (61). The story continued China is one of the fastest-growing marketswith volume maintaining doubledigit growth in nine of the last 10 years. Consumption of Coca-Cola products in China now represents approximately 8% of the company's global volume. The biggest food and drink product transnational is Nestl. In the South, fastest growth is being achieved with its popularly positioned products. These are mostly existing branded products in cheaper or smaller packages. Globally these are expanding at the rate of 27 per cent a year, with total sales of roughly $US 6 billion (62). Half of these sales were in Asia, Oceania and Africa. Brazil is a big market. A corporate release reported, of a factory in the North-Eastern state of Bahia: Nestls factory in Feira de Santana, produces Maggi instant noodles... The plant brings direct and indirect employment opportunities to an economically deprived region, while increasing local workforce skills... It also helps Nestl to reach 50 million consumers in this part of the world. Maggi instant noodles are popular in many countries of Latin America, Asia, Oceania and Africa. The picture above (left) shows a floating supermarket taking all-Nestl branded products to impoverished rural communities in Amazonia (29). Its popularly positioned products include bottled water, and packaged soups, dried soup mixes, stock cubes, instant noodles, soy sauce, instant coffee, creamer, instant chocolate drink, Milo Choco Blazz cereal pillows fortified with iron, Koko Krunch cereal, biscuits, chocolate, confectionery, infant formula, dried milk, and infant follow-on and weaning products. (62,63). Many packaged in sachets, these are cheaper per item
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than conventional equivalents of the same brands or types of product, but generally more expensive weight for weight. Nestls 2012 first half-year report stated that in Asia, Oceania and Africa, sales of about $US 9.5 billion were achieved, with growth at an annual rate of 11.6 per cent. The Zone continued to post double-digit growth The main drivers were brand investment and product innovation, deeper and wider distribution with a multi-tier strategy from popularly positioned products to premiumisation, while investing in capacity and capabilities for future growth The emerging markets delivered double-digit growth most notably in Greater China, Africa, and the Middle East Our new partnerships are enhancing significantly our footprint in China (64). Unilever globally is the worlds second largest food manufacturer, specialising in high-fat products such as margarine, ice-cream, sauces and pot noodles. In 2013 chief executive Paul Polman said Emerging markets again contributed double-digit growth, helping us to exceed 50 billion annual turnover, an important milestone in our journey to double the size of Unilever from 40 billion to 80 billion (14).
In the South: exploitation

In China, India and Brazil and many other countries in the South, long-established and traditional food systems and culinary and dietary traditions have survived. A rapidly increasing proportion of food purchased and consumed is in ultra-processed form, but most is still fresh or minimally processed, or else are processed ingredients with which to make meals. The food supplies of emerging market economies are a long way from being saturated with ultra-processed products. In Brazil for example, these currently supply around 30 per cent of total energy (49). In such countries obesity was rare half a century ago, but rates have steadily risen. In Brazil, population prevalence of population obesity is close to one-seventh (15 per cent) although of overweight and obesity combined the figure is already one-half (65,66). Rates are increasing by around 1 per cent a year, which projects to the same level as the US and UK in around the year 2025 (66).
Throughout Asia, Africa and Latin America, traditional and long-established food
systems, involving cultures in which meals, commensality, and family life are valued and preserved, persist to varying extents. These countries are now the prime targets of transnational corporations. If these industries reformulate and consequently aggressively advertise and promote some of their apparently less unhealthy products as healthy, sometimes even with quasi-medicinal claims, this is certain to accelerate the increase of consumption of ultra-processed products overall. The Big Food corporations want to teach the world to snack, from birth to death. Their main initial competition is from relatively weak in the countries they enter, which they often take over. They displace existing food systems that generate meals
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made with fresh and minimally processed foods and processed culinary ingredients (17, 29, 53), and replace these with relatively expensive branded energy-dense fatty, sugary or salty ultra-processed products. The social, economic and environmental consequences, as well as the impact on health, are devastating. Ultra-processed products undermine healthy eating patterns that are structured and centred on shared meals, by irregular mindless snacking. They destroy authentic food culture which is a source of pleasure and social identity. The strategy of the transnationals is already eroding and eventually threatens to destroy appropriate, economical and sustainable dietary patterns in most parts of the world. Given this, rates of obesity, and of diabetes and other chronic non-communicable diseases, are liable to accelerate. Neoliberalism, also known as casino capitalism, devised for the benefit of the global North, is often embraced in the South by government departments of finance, trade and industry, and external affairs. The destructive effects of free trade on health, economies and the environment are as yet not fully discerned. Until then, the economies of lower-income nations will become more fragile, and increasingly dependent on foreign capital and fluctuations of the money and commodity markets. Deeper penetration of transnational corporations is liable eventually to destroy much of the social, cultural and other identity of countries in the global South. From a global perspective, we judge that reformulated products manufactured by huge transnational corporations, aggressively marketed with health claims, will cause increased harm to public health, and to public goods, throughout the world.
Box 6 Lessons of history

The food and drink product transnationals are the modern equivalents of the West and East India companies that flourished in Europe centuries ago, opening up Asia, Africa and Latin America for trade and profit for the companies, their shareholders, and their governments. The eighteenth century philosopher Adam Smith is seen as the founding father of what, despite continuing proofs of its failure, remains the dominant global economic and political ideology. This gives transnational industry morally and rationally indefensible freedom of commercial action. He is supposed to be the champion of unrestrained commercial activity. This is not true. Here is what he said about concentration of power and its consequences. In his Inquiry into the Nature and Causes of the Wealth of Nations, he wrote: People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices. The next part of this passage is in effect a comment on public -private partnerships. He says: It is impossible indeed to prevent such meetings, by any law which either could be executed, or would be consistent with liberty and justice. But though the law cannot hinder people of the same trade from sometimes assembling together, it ought to do nothing to facilitate such assemblies; much less to render them necessary Adam Smith also declared that tobacco, liquor (he specified rum) and sugar are fit objects for taxation. (59).
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Product reformulation: seven points

Here are seven points about food and drink product reformulation, which summarise why this will not improve public health. They have been revised since the previous paper published in WN in 2012, to take account of events and developments in the last two years.
Reformulated products remain unhealthy
Reformulation is of formulated products. These are ultra-processed. They are energydense. They combine fats and oils, sugars and syrups, starches and flours, salt, preservatives, and other including cosmetic additives, with small amounts if any of whole foods. Modification of their nutrient profile, by reducing sugars or syrups and replacing these with processed oils, starches or artificial sweeteners, or by reducing some salt, or by replacing fats with sugars, or adding dietary fibre or synthetic micronutrients, makes the products at best only somewhat less unhealthy.
Damage limitation exercise
Much and perhaps most influential policy-making supposed to improve the state of public health nutrition, and to reduce and control obesity and chronic noncommunicable diseases, is done in public-private partnerships. These are mostly or solely restricted to international and national government and other officials, and executives usually from the marketing or publicity divisions of transnational corporations. As a prime part of these policies, the transnational and other giant ultra-processed product manufacturers, and their representative, associated and supportive organisations, devise product reformulation strategies that suit their business, and protect or enhance their profits. A main purpose is to evade effective statutory regulation of industry such as that which makes tobacco and alcohol products less available and affordable. They are a damage limitation exercise.
Healthy product development
Reformulation is a massive new product development opportunity. It sanctions explicit or implicit claims on product labelling and promotion, accepted or tolerated by regulatory authorities. Such health or medical claims state or imply that the reformulated products are healthy, in general or in some specific way. They seem to transform what remain unhealthy products into functional foods with powers to prevent or even treat disease. While legal, the claims are deceptive. They also lead to increased sales often of premium priced products by incautious, credulous or vulnerable customers, and often by parents anxious to protect the health of their children and thus likely to purchase products they cannot afford.
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Case study 2 Mild or light cigarettes
Cigarette manufacturers reformulated their products to low-tar varieties, to stop smokers quitting. Big Food transnational manufacturing corporations now use comparable strategies There is no sensible comparison between tobacco and food as a whole. We need food and should be able to enjoy it and retain good health and well-being. Cigarettes and other tobacco products are also different from unhealthy ultra-processed food and drink products. Tobacco is intensely toxic and addictive, and rational advice is not to smoke and to avoid exposure to smoke, whereas occasional or moderate consumption of ultra-processed products is usually harmless. But there are similarities between the strategies of ultraprocessed food product and cigarette reformulation (67), in effect even if not in intention. Starting in the 1950s, Big Tobacco (the industry leaders) was confronted by strong and then overwhelming evidence of the harm done by smoking, and also by increasingly militant health professional and civil society organisations. In response, tobacco corporations began to promote filtered cigarettes, which by the 1960s were the market leaders. They then formulated and heavily promoted low tar, light or mild cigarettes: between 1967 and 2005 the market share of these products rose from 2 to 83.5 per cent. Manufacturers insinuated in advertising and promotion, often using attractive models as shown above, that these reformulated products were harmless. Evidence accepted as final proof that reformulation of cigarettes does not make them less harmful, was published a generation later, in 1991 (68). The strategy of Big Food and Big Snack, to reformulate some of their ultra-processed products, and to claim that the new products are healthy, is a distraction from effective public health measures. In this and other respects it is comparable with the low-tar cigarette strategy.
Small if any net benefits in developed market economies
Almost all discussion of reformulation takes place in the context of developed market economies such as in North America and Western Europe, and other countries whose food supplies may already be close to saturation with ultraprocessed products. Reformulation may be of some limited benefit to human health in such countries, if it results in lower consumption of fat, saturated fat, added sugars
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or salt, and if these reductions are not accompanied by increases in other unhealthy items, and if the only change customers make is from old products to the newly developed products. But notice the ifs. Sales of reformulated products, once positioned as healthy, are likely to be maintained or increase, or be additional to sales of the previous products.
Menace to emerging markets
Transnational food and drink manufacturers are mainly in the ultra-processed product business. Some now aim for double-digit annual growth in the emerging markets notably of Asia, Africa, Latin America and elsewhere. Transnationals have already reduced fat, sugar or salt content of many of their products, or added synthetic micronutrients, often making strong health claims for these premium products, including in countries whose regulatory authorities are under-resourced. This will lead to an increased rate of displacement of traditional and long-established food systems and dietary patterns centred on meals, by ultra-processed snacks and drinks that remain energy-dense, fatty, sugary or salty. Allowing reformulated products to make health claims will thus cause a steeper increase in rates of overweight, and obesity and related diseases.
Distraction from effective action
Reformulation distracts attention from really effective policies and programmes. This diversion, similar to that used by Big Tobacco, is part of corporate strategy. From the public health point of view, any possible beneficial changes consequent on product reformulation would be very small relative to what could be achieved by fiscal and other statutory regulation. These should assure food supplies higher in fresh and minimally processed foods, preserve national agricultural ecosystems and biodiversity, make agriculture a viable social and economic activity, support local food traditions, promote cooking in urban settings starting in schools, and limit availability of ultra-processed products.
Rational policies are needed
National governments, UN and other international organisations, and other independent actors, should develop statutory policies and actions to prevent and control obesity and chronic non-communicable diseases and to promote positive health and well-being. Transnational and other corporations whose profits depend on the sale of unhealthy products should not be involved in the formulation of these policies and programmes. Overall public health strategies should include very substantial investment in healthy food systems and supplies, and an end to the promotion of any type of ultra-processed products as if they were healthy. Explicit or suggested health claims for reformulated products should be prohibited.
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Conclusion
Here are five suppositions. Suppose that most people in most countries were overweight and obese. Suppose that practically all regions and countries were fully industrialised, with food systems concentrated in the hands of huge industrial corporations. Suppose that these industries made radical changes in the formulation of their products, in the context of general diversification base their businesses on fresh and minimally processed foods. Suppose that most people in most countries were willing and able to afford new formulations and products, and chose these products, even when they were more expensive. Suppose that all the most powerful institutions, governments and corporations in the world were genuinely committed to the preservation, development and creation of food systems based on fresh and minimally processed foods, and that reformulation of processed products was just one aspect of such a grand plan. If all this was true, product reformulation would make a real difference. But of course none of these suppositions is true. Food and drink product reformulation will not improve public health. It is relatively harmful when, as now, it is a distraction, used in place of more effective strategies involving the rational use of statutory regulations. It is absolutely harmful when it is a new form of exploitation, where advertising and marketing of reformulated branded snack and other convenience products that make or imply health claims, accelerate the erosion and displacement of established appropriate and economical food systems and dietary patterns based on meals. In the South, long-established traditional food systems result in dietary patterns that are culturally appropriate, environmentally sound, economically sensible, climatically rational, able to sustain rural populations, and which are well understood by settled populations. These are now in danger of being wiped out by the incursion of ultraprocessed products. This catastrophe can only be made worse by products marketed as if they are healthy. Everybody professionally or personally concerned with the preservation and protection of public health, including leaders in government and public interest organisations, should give first and foremost priority to the promotion of healthy food systems and supplies, to include recognition and support of healthy meals, dishes and foods. This should include close collaboration and partnership with representatives of those sectors of industry that now or potentially are in the business of healthy food which is also good for society and the environment. These do not include Big Food or Big Snack, the transnational manufacturers of ultra-processed products. Their overall strategy is in effect to teach the world to snack their branded ready-to-consume products, throughout life (9). This process is being accelerated by the formulation and promotion of ultra-processed products that make or imply health claims.
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Status
Concept, drafting and final text approval: CAM, GC. Funding for this commentary: none. Conflicting or competing interests: none declared. Work on The Food System and specifically on the significance of food processing, is originated at the Centre for Epidemiological Studies in Health and Nutrition (NUPENS), School of Public Health, University of So Paulo (USP). Members of NUPENS team include Renata Bertazzi Levy, Rafael Claro, Jean-Claude Moubarac, Ana Paula Martins, Maria Laura Louzada, Larissa Baraldi, Daniela Canella. Readers may make use of the material in this paper if acknowledgement is given to the Association, and WN is cited. Cite as: Monteiro CA, Cannon G. The Food System. Ultraprocessed products. Product reformulation will not improve public health. [Commentary]. World Nutrition, February 2014, 5, 2, 140-168. All WN contributions are obtainable at www.wphna.org. World Nutrition commentaries are reviewed internally or by invitation. All contributions to World Nutrition are the responsibility of their authors. They should not be taken to be the view or policy of the World Public Health Nutrition Association (the Association) or of any of its affiliated or associated bodies, unless this is explicitly stated.
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THE FOOD SYSTEM

The big issue for nutrition
This commentary continues the series begun in World Nutrition and elsewhere, as referenced above. The overall theme of the series is the global industrial food system, its significance, and its impact on dietary patterns, health and well-being, food culture, public policies, society, economies, the environment, and the biosphere, in the past, now, and for this century. Future contributions will be looking at various aspects of the food system as the big issue for nutrition. Contributions published in WN so far have mostly been concerned with food processing, and what happens to food and to us as a result of different types of processing. We have focused on ultra-processed products, as we do here. We identify these as the main dietary cause and explanation of what is now uncontrolled pandemic obesity and related chronic non-communicable diseases.
NOVA
Our thesis derives from NOVA, a wholly new food classification. This replaces all those that divide foods into conventional groups (such as cereals and cereal products, meat and meat products). Instead, we identify industrial processing as the crucial determinant of food and diet quality, the risk of disease, and prospects of good health and well-being. In our system, Group 1 is of fresh and minimally processed foods. Group 2 is of processed culinary ingredients. These are combined and made into meals, as symbolised above by the full cooking pot. Group 3 is of ready-to-consume products. Most of these are ultra-processed, as symbolised above by the cheese-bacon-burger.
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World Nutrition Volume 5, Number 2, February 2014

The Food System: Ultra-processed products. 2014 Position paper

Product reformulation will not improve public health

World Nutrition Volume 5, Number 2, February 2014

World Nutrition Volume 5, Number 2, February 2014

The case for and against

The case for

World Nutrition Volume 5, Number 2, February 2014

The case against

World Nutrition Volume 5, Number 2, February 2014

Box 1 The duty of governments

World Nutrition Volume 5, Number 2, February 2014

Reformulated products are unhealthy

Box 2 Ultra-processed products

World Nutrition Volume 5, Number 2, February 2014

World Nutrition Volume 5, Number 2, February 2014

Not a lot changes

Box 3 Removal of trans-fatty acids

World Nutrition Volume 5, Number 2, February 2014

What private sector means

Private sector means the transnationals

Or to be more precise, Big Snack

World Nutrition Volume 5, Number 2, February 2014

Box 4 Transnational corporations

World Nutrition Volume 5, Number 2, February 2014

What partnership means

Reformulation is where the action is

World Nutrition Volume 5, Number 2, February 2014

World Nutrition Volume 5, Number 2, February 2014

Case study 1 Reduced sugar Froot Loops

World Nutrition Volume 5, Number 2, February 2014

World Nutrition Volume 5, Number 2, February 2014

The global North

World Nutrition Volume 5, Number 2, February 2014

Saturated markets in the North

In the North, distraction

World Nutrition Volume 5, Number 2, February 2014

The global South

Box 5 Regulation in the public interest

World Nutrition Volume 5, Number 2, February 2014

Booming business in the South

World Nutrition Volume 5, Number 2, February 2014

In the South: exploitation

World Nutrition Volume 5, Number 2, February 2014

Box 6 Lessons of history

World Nutrition Volume 5, Number 2, February 2014

Product reformulation: seven points

Reformulated products remain unhealthy

Damage limitation exercise

Healthy product development

World Nutrition Volume 5, Number 2, February 2014

Case study 2 Mild or light cigarettes

Small if any net benefits in developed market economies

World Nutrition Volume 5, Number 2, February 2014

Menace to emerging markets

Distraction from effective action

Rational policies are needed

World Nutrition Volume 5, Number 2, February 2014

World Nutrition Volume 5, Number 2, February 2014

World Nutrition Volume 5, Number 2, February 2014

THE FOOD SYSTEM

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